Childhood Onset Schizophrenia

Schizophrenia
characterized by psychosis or loss of touch with
reality
average age of onset is 18 for males and 25 for
females
childhood-onset (COS) younger than 13
early (adolescent) onset (EOS) younger than 18
continuous with adult-onset
Proposed DSM-5 Diagnostic Criteria
Must have A-F
A. Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated). At least one of these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior, including catatonia
5. negative symptoms
B. For a significant portion of the time since the onset of the disturbance, one or more major
areas of functioning, such as school, work, interpersonal relations, or self-care, are markedly
below the level achieved prior to the onset (or when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or by an attenuated form of two or more symptoms listed in Criterion A (e.g.,
beliefs perceived as odd, perceptual experiences described as out of the ordinary).
D. Schizoaffective Disorder and Depressive or Bipolar Disorder With Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred
during active-phase symptoms, their total duration has been less than half of the total duration of
the active periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., an abused
drug, a medication) or a general medical condition.
F. If there is a history of Autism Spectrum Disorder or other communication disorder of childhood
onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or
hallucinations are also present for at least 1 month (or less if successfully treated).
Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms

delusions
False beliefs
A 9-year-old boy was convinced he was a dog (his
parents were German Shepherds) and was growing
fur, and on one occasion, refused to leave a
veterinarian's office unless he received a shot.
A girl believed that the "evil one" was trying to
poison her orange juice.
Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms

hallucinations
False Perceptions
An 11-year-old boy heard both "good" and "bad
voices." The bad voices tell him to hit others and
that they will kill the good voices if he does not
obey. The "good" voices say things like "help your
mom with dinner.
A 9-year-old boy reported the kitchen light saying to
do things and "to shut up.
A 12-year-old boy saw a ghost (man) with red,
burned, scarred, and cut face on multiple occasions
and in different locations. He had been seeing this
since age 5.
A 5-year-old boy felt snakes and spiders on his
back

Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms

disorganized speech
incoherent, bizarre, lacking logical organization or
meaning
"I used to have a Mexican dream. I was watching
TV in the family room. I disappeared outside of this
world and then I was in a closet. Sounds like a
vacuum dream. It's a Mexican dream. When I was
close to that dream earth, I was turning upside
down. I don't like to turn upside down. Sometimes I
have Mexican dreams and vacuum dreams. It's real
hard to scream in dreams.
Loose associations
Made up words or phrases
Perseveration
Clanging
Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms

abnormal psychomotor behavior
stereotyped repetitive
behaviors similar to ASD
purposeless excitement
and hyperactivity
catatonic behaviors
mutism
motionlessness
staring
waxy flexibility



Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms

negative symptoms
restricted affect
avolition - reduction, difficulty, or inability to initiate
and persist in goal-directed behavior
alogia poverty of speech
asociality lack of desire to form relationships
anhedonia inability to experience pleasure
Proposed DSM-5 Diagnostic Criteria:
Criterion A
Two (or more) of the following, each present for a
significant portion of time during a 1-month period
(or less if successfully treated). At least one of
these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior,
including catatonia
5. negative symptoms, e.g., diminished emotional
expression or avolition

At least 1
Proposed DSM-5 Diagnostic Criteria
Must have A-F
A. Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated). At least one of these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior, including catatonia
5. negative symptoms
B. For a significant portion of the time since the onset of the disturbance, one or more major
areas of functioning, such as school, work, interpersonal relations, or self-care, are markedly
below the level achieved prior to the onset (or when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or by an attenuated form of two or more symptoms listed in Criterion A (e.g.,
beliefs perceived as odd, perceptual experiences described as out of the ordinary).
D. Schizoaffective Disorder and Depressive or Bipolar Disorder With Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred
during active-phase symptoms, their total duration has been less than half of the total duration of
the active periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., an abused
drug, a medication) or a general medical condition.
F. If there is a history of Autism Spectrum Disorder or other communication disorder of childhood
onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or
hallucinations are also present for at least 1 month (or less if successfully treated).
Proposed DSM-5 Diagnostic Criteria
Must have A-F
A. Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated). At least one of these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior, including catatonia
5. negative symptoms
B. For a significant portion of the time since the onset of the disturbance, one or more major
areas of functioning, such as school, work, interpersonal relations, or self-care, are markedly
below the level achieved prior to the onset (or when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or by an attenuated form of two or more symptoms listed in Criterion A (e.g.,
beliefs perceived as odd, perceptual experiences described as out of the ordinary).
D. Schizoaffective Disorder and Depressive or Bipolar Disorder With Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred
during active-phase symptoms, their total duration has been less than half of the total duration of
the active periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., an abused
drug, a medication) or a general medical condition.
F. If there is a history of Autism Spectrum Disorder or other communication disorder of childhood
onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or
hallucinations are also present for at least 1 month (or less if successfully treated).
Proposed DSM-5 Diagnostic Criteria:
Criterion C
Symptoms must persist for 6 months*
1 month must be active-phase (positive) symptoms
(delusions, hallucinations, disorganized speech)*
remainder can be only negative symptoms or sub-
clinical positive symptoms
prodromal phase decrease in functioning leading up
to psychosis
residual phase symptoms remaining after active-
phase has subsided


*less if successfully treated
Proposed DSM-5 Diagnostic Criteria
Must have A-F
A. Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated). At least one of these should include 1, 2, or 3.
1. delusions
2. hallucinations
3. disorganized speech
4. grossly abnormal psychomotor behavior, including catatonia
5. negative symptoms
B. For a significant portion of the time since the onset of the disturbance, one or more major
areas of functioning, such as school, work, interpersonal relations, or self-care, are markedly
below the level achieved prior to the onset (or when the onset is in childhood or adolescence,
failure to achieve expected level of interpersonal, academic, or occupational achievement).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or by an attenuated form of two or more symptoms listed in Criterion A (e.g.,
beliefs perceived as odd, perceptual experiences described as out of the ordinary).
D. Schizoaffective Disorder and Depressive or Bipolar Disorder With Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred
during active-phase symptoms, their total duration has been less than half of the total duration of
the active periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., an abused
drug, a medication) or a general medical condition.
F. If there is a history of Autism Spectrum Disorder or other communication disorder of childhood
onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or
hallucinations are also present for at least 1 month (or less if successfully treated).
diagnosis
difficult to diagnose because
symptoms may be
indistinguishable from typical
aspects of childhood
imaginary friends/magical
beliefs
sleep disturbances
early symptomatology is
similar to autism spectrum
disorder and communication
disorders
course
onset is insidious and non-episodic
neurodevelopmental impairments early in life
such as delay in language/speech, linguistic
ability, motor coordination, and poor psychosocial
functioning
rapid deterioration
chronic course
periods of improvement are followed by relapses
the earlier the age of onset, the worse the
prognosis
less likely to finish high school
fewer stable relationships
most are able to work in some form
25% attempt suicide in adulthood


prevalence
1 in 10,000 (adult-onset is 1 in 100)
4% of schizophrenia cases are EOS, 1% are
COS
Twice as many boys diagnosed with COS,
however age of onset is equal for boys and girls
Externalizing vs internalizing
Misdiagnosis of ASD
Referral bias
comorbidities
99% of COS and childhood-onset schizoaffective
disorder have at least 1 comorbid diagnosis
84% ADHD
Stimulants exacerbate schizophrenic symptoms
43% ODD
30% depression
25% separation anxiety disorder
causes
neurodevelopmental
abnormalities in
synaptic pruning (too
many or too few)
reduced cerebral
volume
smaller thalamus
rate of gray matter
volume loss
overabundance of
dopamine
causes
genetic
heritability
adult-onset schizophrenia is highly heritable (~.81);
concordance between MZ twins is 50%
heritability is even higher in early-onset
lots of genes are likely involved
environmental
prenatal viral infections, poor nutrition
lack of oxygen at birth
psychosocial
abuse
stressful life circumstances
risk and protective factors
factors associated with negative outcomes
deceptive onset unclear if child has schizophrenia
onset prior to age 12
premorbid dysfunction if dysfunction existed prior to
onset
severe symptoms during acute phase
low cognitive functioning
older fathers
living in an urban area
low SES
ongoing abuse
factors associated with more positive outcomes
high IQ
mostly positive symptoms
social competence
supportive family relationships
treatment
antispsychotics
dopamine antagonists
(blocks dopamine
production)
Typical (1
st
generation)
thorazine, haldol
help with positive systems
high risk of tardive
dyskinesia
atypical (2
nd
generation)
clozapine, risperidone,
olanzipine
help with positive and
negative symptoms
side effects: excessive
weight gain, seizures,
decreased white blood
cells, heart problems, liver
problems, diabetes, etc.


treatment
psychosocial
treatments
cognitive-behavioral
therapy
social and basic life
skills training
Family
psychoeducation